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PYLORIC EXCLUSION IN PUD MANAGEMENT dr. Agi Satria Putranto, SPB(K)BD

PYLORIC EXCLUSION IN PUD MANAGEMENT

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Page 1: PYLORIC EXCLUSION IN PUD MANAGEMENT

PYLORIC EXCLUSION INPUD MANAGEMENT

dr. Agi Satria Putranto, SPB(K)BD

Page 2: PYLORIC EXCLUSION IN PUD MANAGEMENT

Pyloric exclusion often is used to divert the GI steam and followed by gastro jejunostomy anastomostic

Page 3: PYLORIC EXCLUSION IN PUD MANAGEMENT
Page 4: PYLORIC EXCLUSION IN PUD MANAGEMENT

Current Indications for Surgical PUD

1. Bleeding

2. Perforations

3. Obstruction

4. Failed medical therapy

5. Risk of malignancy

Page 5: PYLORIC EXCLUSION IN PUD MANAGEMENT

The goals of PUD Surgical Procedure

1. Permit ulcer healing

2. Prevent of treat ulcer complications

3. Address the underlying ulcer etiology

4. Minimize postoperative digestive consequences

Page 6: PYLORIC EXCLUSION IN PUD MANAGEMENT

To choose the best operation, the surgeon must consider :

1. The characetistic of the ulcer (location, chronicity, type of complication)

2. Etiology (acid hypersecretion, drug-induced, possible role of H. pyloric)

3. The patient (age, nutrition, comorbid illnesses, condition on presentation)

4. The operation (mortality rate, side effects)

Page 7: PYLORIC EXCLUSION IN PUD MANAGEMENT

Simple Ulcus

Perforated duodenal ulcer

Peritonitis

Operative

• Omental pastching with truncal vagotomy

• Pyloroplasty or omentalpatching with HSV • Omental patching/plug

• H. pylori testing and treatment

“Unusuall” condition of Duodenal Ulcer

• OmentalPatching/plug

• T-tube inserted • Pyloric Exclusion

• Perforation >24h• Contrast study

confirms sealed perforation

Conservative Theraphy

Page 8: PYLORIC EXCLUSION IN PUD MANAGEMENT

Pyloric Exclusion Procedure

There are two ways to close the pylorus :

1. Suture from within the stomach

2. Stapled closure

Page 9: PYLORIC EXCLUSION IN PUD MANAGEMENT
Page 10: PYLORIC EXCLUSION IN PUD MANAGEMENT

Find the pyloric ring make an suturing with ‘O’ technique or interact suturing with absordable

suture

Construct an anterior gastrojejunostomy by bringing up a loop of jejenum and suturing it at the site of the gastrotomy

Place omentum over the duodenal suture line and place drains in close proximity to it

Create an anterior gastrotomy

Repair duodenal ulcer

Page 11: PYLORIC EXCLUSION IN PUD MANAGEMENT

The indication of Pyloric exclusion common use in complex duodenal repair especially injury and rare in duodenal ulcer

Page 12: PYLORIC EXCLUSION IN PUD MANAGEMENT

Pyloric exclusion is recommend for severe injure Grade II and Grade III

Page 13: PYLORIC EXCLUSION IN PUD MANAGEMENT

Anatomic Complication – Pyloric Exclusion

1. Leakage from duodenal closure

2. Duodenal obstruction

3. Failure of pylorus to reopen Alternatively pylorus may reopen before repair is healed

Page 14: PYLORIC EXCLUSION IN PUD MANAGEMENT

PYLORIC EXCLUSION IN RSCM1. Diagnose : Duodenum perforation (Pars 2, Iatrogenik)

Treatment : Laparatomy

Duodenorraphy

Pyloric exclusion, Gastrojejenumstomy

2. Diagnose : Penetrating abdominal gunshot wounds with abdominal peritonitis, region of the

corpus alineum

Treatment : Laparotomy – exploration

Duodenorraphy

Pyloric exclusion, Gastrujejenumstomy

Double barrel transversum colostomy

3. Diagnose : Residif Pseumiksoma + Insisional hernia + Duodenum perforation (Iatrogenik)

Treatment : Pyloric exclusion

Primer suturing duodenum perforation

Gastojejenumstomy

Page 15: PYLORIC EXCLUSION IN PUD MANAGEMENT

THANK YOU